Many of us cling to our “jerry-rigged” system even as it fails us, but early in his career, health reform expert Jacob Hacker saw a clear need for change.

Question: What has been your personal experience with the healthcare system?

Jacob Hacker: Well, I think my experiences with the healthcare system have been pretty similar to most Americans. I was born into American healthcare and have grown up not aware that there was anything different. When I was in college, I went and worked on Capital Hill for then-Representative Ron Wyden—he has since gone over to the Senate side—for his chief health assistant. While I was there I came to discover not only what I had already known, which is that there are a lot of problems in American healthcare, but that our system was very different from those systems in other countries.

So one of the things I did when I went back to college after that summer is started studying why the United States had ended up with such a distinctive system, and ended up writing my senior thesis on the rise and eventual fall of the Clinton health plan, and wrote my dissertation while I was at Yale on the development of America’s distinctive system of workplace social benefits, including healthcare but also retirement pensions.

So I've been studying this now for most of my adult life, and at the same time I've gotten more and more involved in it as a participant in the debate rather than just a student of it. The story there, which is worth telling, is that as I was studying the development of our distinctive system, I was always wondering why is it that it's so hard to reform American healthcare. After all, we've had efforts from the early 20th century to try to do this, to really address the problems in American healthcare, and they've only grown worse. My answer was that it's hard in part because we failed in the past and we've come to rely so heavily on the sort of jerry-rigged system of private employment-based benefits. And that Americans, while they're worried about the cost of those benefits and worried about their security, and millions of Americans don't have coverage at all or who are unprotected against medical costs, that at the same time people are fearful of changing the arrangements they've come to rely on.

That's why it's so hard. And I think that's the central reason why this debate is so bitter and fierce. There is really a lot of fear that can be provoked by opponents of reform, and it's amazing we've come as far as we have in the debate, given the history of past defeats.

Recorded on November 9, 2009
Interviewed by Austin Allen